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Filling a gap: Ontario’s walk-in clinics

About one in four Ontarians visit a walk-in clinic each year.

While the government has made access to family doctors a key priority, there is no policy framework for walk-in clinics.

Although walk-in clinics have been part of Ontario’s health care landscape for decades, they remain controversial. Walk-in clinics have generally been excluded from government efforts to improve access to primary care services, and little is known about the services that walk-in clinics provide and the reasons why patients frequent them.

In the past decade, the Ontario government has made significant reforms to primary care, including a shift toward group practice models such as Family Health Teams and away from fee-for-service medicine. However, doctors who work in walk-in clinics in Ontario continue to be paid almost exclusively by fee-for-service (i.e., a payment for each visit or service) and usually work without the help of an interdisciplinary team.

Some experts argue that walk-in clinics promote duplication of health care services and can drive up health care costs as patients seek care from multiple providers in an uncoordinated way. Yet the convenience of walk-in clinics cannot be ignored, especially for patients who do not have a family physician or cannot see their family physician when they need to.

“Bottom of the heap” when it comes to timely access to family doctors

Ontario’s Action Plan for Health Care, announced in February 2012, includes “faster access to stronger family health care” as one of the top three priorities for Ontario’s health care system.

This priority makes sense given that half of Ontarians are currently unable to obtain a timely appointment with their family doctor or a nurse when they are sick. In fact, in an international survey of fourteen countries, Canada ranks near the bottom in accessing primary care when it is needed urgently. Rick Glazier, a family doctor and researcher at St. Michael’s Hospital in Toronto says “Canada is at the bottom of the heap when it comes to timely access to care, which explains why we’re at the top of the heap when it comes to emergency department visits.”

In the United Kingdom, more than 70% of people are able to get same or next day care. The National Health Service also operates walk-in centres that focus on treating minor issues. These walk-in clinics see nearly 3 million patients per year and take pressure off traditional primary care practices as well as emergency departments. However, they are more integrated into the rest of the primary care sector than walk-in clinics in Ontario, and are often staffed primarily by nurses rather than doctors. Jonathon Tomlinson is a general practitioner (GP) who works in a family practice in Hackney, a suburb of London. His practice includes a walk-in clinic that serves both registered patients who do not have a scheduled appointment as well as patients who have never registered with the practice.

Like many family doctors in Ontario, Tomlinson believes that patients are best served when they can visit their regular practice. He notes that “if the problem is that patients aren’t getting appropriate access to GPs, the answer isn’t to go to a walk-in around the corner from the GP, it’s to fix GP practices.”

In contrast, David Peachey, a family doctor who works in a Toronto walk-in clinic and previously served as Director of Professional Affairs for the Ontario Medical Association says that “the proper role of walk-in clinics is to be a safety valve in the system, to assist traditional family medicine practices.” Yet, walk-in clinics in Ontario are not required to provide information to a patient’s regular family doctor after providing care to a patient.

The government’s Action Plan includes a commitment to improve “access to the right care, at the right time, at the right place” and notes that Ontarians have a number of different options other than emergency departments when they are in need of immediate care for non-urgent concerns. The website includes a video, reproduced below, describing the services that walk-in clinics offer, as well as a tool to locate nearby walk-in or after hours clinics. Yet the clinics themselves operate in a relative policy vacuum.

What we know (and do not know) about walk-in clinics

An annual survey conducted by the Ministry of Health and Long-Term Care until 2010 found that about 25% of Ontarians used a walk-in clinic in any given year. Tori Gass, a Ministry of Health and Long-Term Care spokesperson, noted in an e-mail to healthydebate.ca that “walk-in clinics are considered private businesses” and that the Ministry of Health and Long-Term Care “is not always made aware if a clinic closes or a new one opens.” As a consequence, the Ministry of Health and Long-Term Care does not know exactly how many walk-in clinics we have in Ontario.

Rick Glazier adds that “we have very little data on walk-in clinics in Ontario” and it is currently “not possible [for the Ministry of Health and Long-Term Care or a researcher] to easily figure out whether a primary care service was delivered in a family doctors’ office where they provide comprehensive care, or if it’s in a walk-in clinic.” We also don’t know whether patients visit the same walk-in clinic repeatedly for many years, in which case the clinics may be providing ongoing care, or whether the care is more episodic in nature.

Innovation to improve access to primary care

One Ontario initiative designed to improve primary care is the Learning Community organized by Health Quality Ontario. This initiative was previously known as the Quality Improvement and Innovation Partnership, and provides primary care practices with training and support for quality improvement activities. One activity supported by this initiative is Advanced Access, a scheduling philosophy that promotes same day access.

If better scheduling could improve access to family doctors, then perhaps fewer people would need to use walk-in clinics. However, many patients use walk-in clinics because they are more conveniently located than their regular family doctor, and not because their regular doctor doesn’t provide same day access. For example, someone who lives in the suburbs but works in downtown Toronto might visit a walk-in clinic near their office rather than going to their family practice closer to home.

Rick Glazier suggests that in spite of ongoing reforms and efforts to improve access to primary health care services “there will always be a need from patients for quick access to care for minor, but acute, issues.” Walk-in clinics are likely to always have a place in our health care system, and Ontario’s primary care strategy needs to consider what their optimal role should be.

Should more efforts be directed at gathering information and developing policies related to walk-in clinics in Ontario?

Yes, more information about walk-in clinics should be collected to help design better policies in primary care

Enter the debate: reply to an existing comment

25 comments

Anne-Marie TynanAugust 9th, 2012 at 11:46 am

Hi — this is a great & informative article. However, when I speak to my friends about healthcare or these kinds of issues, virtually all of them have gone to or still continue to go to a walk-in clinic for occasional care. No one seems to know why they should or shouldn’t go to a walk-in. The main reason my friends give is because their family physician is located farther away from their home than they wish to travel they head, instead, to the nearest walk-in. I think the real issue is most people have no idea about what their doctors or clinics provide including after-hours services or walk-ins. People just want to see a doctor quickly & go wherever is closest & most convenient at the time. I think the biggest challenge is educating the public about the variations of health services available through their own doctors/clinics. Even my own family physician, who is great, has never really explained to me how her practice works and/or what services are part of the practice. I know I get good care but am still a bit unsure about how it all works! I also wonder about the future possibility of my family physician calling me (like my dentist does) to remind me to book a physical or follow-up appointments.

Ann-Marie T
Agreed All patients should be educated on the types of primary care provided in this province. We may then actually get more people active about making it more effective. Much of the “private business model” that is Walk-in Clinics is partly extra income for primary care providers so “rocking the boat” is not on their priority list.
It is poor Acute care and poor short term diagnostic preventive care as well as extremely poor public policy. This model needs to be re-imagined. We have the infrastructure of Local Integrated Health Networks to do this.
We have a lack of public education and political will . . .
Fee-for-Service is wrong headed if cost containment and effective Health provision across the spectrum of that definition is to be embraced.
Health is NOT a business. Health for humans and the planet as a whole is a right to the best life possible.

The last and final time I went to a walk-in clinic I had a bad case of bronchitis that did not react to the first antibiotic used. I asked to see the same doctor who treated me three days earlier and I was told this was not permitted. I couldn’t believe that they could not understand the importance of continuity in treatment but was told that this was clinic policy. Although I felt pretty awful, I waited until the office covering for my primary doctor was open the next day and learned that I now had pneumonia. In my opinion, walk-in -clinics can provide a convenient short-term service. However their effectiveness is limited by this type of policy and exacerbated as they do not share information with other components of the system (another example of the costs of not having a comprehensive health information system).

This is an important and timely discussion. We absolutely need more information about walk-ins. We need to start with a clear definition of walk-in clinics. I don’t think it’s as black and white as many people think. It may be a little bit like pornography or art in that it’s hard to define but easy to identify.

We can define emergency care. We can also define comprehensive family practice, using some sort of basket of services that is provided to patients on an ongoing basis. It’s less easy to define Urgent Care Centres. The MOHLTC has designated some places as UCCs, but others who appear to offer similar services are left out. But what is a walk-in clinic?

Some practices provide what I would call comprehensive family practice to some patients while providing walk-in type care to others. These are a sort of hybrid. And they appear to offer excellent care.

In this time of economic restraint we need to make sure that money is well spent on all types of care and that means we should evaluate the value added to the system for walk-in care. But we really need to spend some time making sure we all have a common definition that makes sense.

Lastly I would like to point out that while it makes intuitive sense that improving the access for a patient to his or her usual primary care physician or NP will decrease the demand for walk-in clinics, I’m not sure that there is a lot of evidence to support that assumption. Many physicians have worked valiantly to implement advance access or day of choice scheduling and still see their patients go to walk-ins. At some point we need to have a serious discussion about patient accountability.

For me, my schedule, and my family, our local walk-in clinic is the best solution to our busy and varied schedule for important, non life threatening issues.

Our family doctor was semi retired, and although he would have been my first choice, most times it wasn’t possible to see him without taking time off work or school for my sons, or waiting a week or so for an appointment. Since then I’ve signed up with the local NP clinic, with my previous physician as consultant, which is good, but if there is an urgent, non life threatening issue, I will still visit the local walk-in clinic. The last thing I want to do is wait 8 hours, possibly more, at our local hospital, and pay $4.00 per hour parking.

There is a gap between between hospitals and physicians’ practices that walk-in clinics fill, and I’m happy to continue using the walk-in clinic when needed. It’s a matter of not having to take time off work or school, lose money, and so on. The walk-in clinic is more convenient and efficient.

I find walk-ins to be hit or miss in terms of quality, but at least I can get in and out within the day. My family doctor has terrible hours but I swear they were the only place in the city actually accepting patients.

Here’s the thing, walk-ins are generally open from 9 – 5, sometimes even 9 – 7 on work days. I even have one near my house that is open on the weekends. My GP is closed weekends, Monday is a half day for some reason, Tuesday they are closed all day (?) not sure why. Wedensday is from 1pm to 7pm, Thusday is 9 – 3, Friday is 9 – 7. The hours are confusing, seem to change every month and aren’t actually listed anywhere for me to see.

My fiance got fired from his family doctor for visiting the hospital to much and now he’s having a hard time getting a new doctor. I even tried to see if my doctor would take him on, but he said no. I’m afraid to go to the hospital now, cuz I don’t want to get fired from my doctor. We live in North Bay, Ontario and our doctors are in Powassan, Ontario. I finally got to see my doctor, but he doesn’t believe me about my hip giving out on me when I walk long distances. He thinks I just need exercise, but I’m very active.

I went to a walk- in clinic just the other day for some medication and I knew right from the start that he just wanted the money from my visit. I was at the clinic for not even 2 minutes and he said their was nothing wrong with me? He was also a real Jerk! The best part is I went to another clinic and the Doctor prescribe me a prescription,Go figure!

I have had better healthcare at the walk-in-clinic I use than my son has at his GP. Because there are several doctors at the clinic, they tend to channel cases to the doctor with the most relevant experience. That can’t happen at the GP. Furthermore they can pull up my file each time no matter which doctor within the clinic I saw in the past. Friends have claimed a family doctor will know your situation better and provide continuity but with my son’s doctor, there is no way he knows our names without looking at the file and no way he knows the reason for our last visit. The only thing he knows is how to read his own scrawl (the clinic uses typed notes on iPads). I frankly see little argument in favour of a family practitioner. As far as whisking you in and out in a hurry, that happens at both places. I have to tell them to slow down. One thing that bothers me is the notion of “one appointment, one ailment” (or at most 2). I think that is driven by twisted incentives in the billing systems.

You’re right about your final comment. Overall, physicians are not paid to talk, think, or listen. They are paid to do. Your appointment is coded as an “encounter” with a specific reimbursement attached to it; something along the lines of 30 bucks. Whether the doc spends 2 minutes with you to refill a script, or 30 minutes with you reconciling multiple complaints, he gets the same 30 bucks.

The billing system makes it quite clear that a doctor’s mind is unimportant. This is why nobody wants to do family practice, and that those that do are forced to do this “one problem per visit” nonsense to keep their practices afloat.

The only solution to this is to increase the billing rates and to figure out a way to bill per clinical decision, not per encounter or procedure.

As a resident of High Park, Toronto I had a MD I rarely visited as I worked in Don Mills and travelled by TTC so it took a bus, 3 subway systems and the King street car to get me to the MD, not easy during rush hour. I had a walk in clinic near my work in Don Mills and a walk in clinic that took appointments in the evenings in Chester Village(there are no walk in clinics open evenings or weekends in High Park). Mostly working people use walk in clinics as they need urgent care during evening or weekends and the health minister has been busily closing hospital clinics and community clinics with 600 person waiting lists are not available. Not everyone wants to go to the emergency room of a hospital if they need urgent care

I feel walk in clinics are a great concept if you stop the doctors from using them as money making turnstiles and have doctors spend more time per visit with the patient. Doctors have to realize that clients are not part of a robotic process and need extra time to be examined and diagnosed properly. How to achieve this might mean more government intervention to see how these clinics are run.

People don’t realize that a walk-in clinic is not an alternative to a family doctor. My daughter waited almost a year for a surgeon’s visit which had been arranged by the clinic. They were new to the city then, and could not immediately find a doctor . She has such severe back damage that there is danger of permanent disability. She cannot lay down and can only sit and lean back.
Today was the visit …. she went to the surgeon’s office.
He told her that the paper request from the clinic said ‘pediatric’ and he could not help her…. go to another doctor. He DID tell her she had better get an operation soon.
My daughter came home and wept. I am furious with the lack of skill at that clinic. Unbelievable! If these are private businesses, the public should be aware…. and not think of them as a valid alternative to quality care. If they are not, they should be monitored and meet basic requirements like being able to read, write.

Hi My daughter and grandson went to Urgent care walk in clinic at 10 am didn’t not get to see the Doctor till 1;30 om people came into the office then went in to see the Doctor after awhile my daughter finally ask another patient if she had an appointment her reply was yes? well my grandson temp was 103 degrees and not well at all and being the age of two didn’t help because he was so cranky But I don’t understand the definition of a Walk In Clinic if these clinics are being paid by our tax dollars these Dr’s shouldn’t being using them for they’re private practices

I went to a walk in clinic and the doctor kept looking at the floor instead of at me. I had a painful rash on my ribs and he gave me a prescription for oitment. I felt like he did not even care because he never looked at me and perhaps glanced at my rash a second. His secretary told me he was Muslim and could not look at a woman especially at Ramadam. The women working there were all devout Muslim with full head dress. This was on Sheppard Ave E at Birchmount . I ended up going to emergency when the pain got really bad and I had shingles. Doctors who refuse to look at a woman should not be allowed to practice here in Canada. What a Joke!!!!

There are multiple “shortage” specialties, like family medicine, psychiatry and pathology, where anyone from abroad is essentially allowed to practice with relaxed standards in order to “fill the need”.

Shingles is a serious diagnosis that a first-year medical student should be able to make. This doctor clearly wasn’t paying attention. It being Ramadan is not an excuse.

Not being able to examine a patient because of religious reasons is antithetical to being a physician. I would call the CPSO and complain about this particular doctor. That kind of behavior is not accepted in medicine.

I have tried to find out more about the governing of walk-in clinics – their regulations and policies, etc, but gotten nowhere. The CPSO only deal with the physicians. The Ministry of Health has nothing to say on the subject, though I got the impression walk-in clinics are seen as businesses, like restaurants. Where can one go to find out about them? They certainly aren’t geared to older people with chronic illnesses.

Reading this article opened my eyes to why walk-in clinic doctors seem not to do a good job of collecting any information not really talking a patients issues seriously. To how I and others have endure and discussed the walk-in clinics lack of care has us wanting to do a documentary on Clinics and they way they treat patients of different backgrounds.
The public needs to see not hear.

After a terrible experience at a walk in clinic in Orangeville Ontario I can not find out who owns the clinic or who they are accountable to. The doctors yes but the owner no.
If the business is to receive public funds they need to be held accountable as well

A list of walk-in clinics should be available that rates the clinics in all areas including the front office staff. I am in the process of locating a new doctor as I can no longer deal with the lack of respect that the front office staff and upper management have for the patients not to mention the apparent lack of proper record keeping. Absolutely no issues with the doctor, she is great. As patients we need to know which clinics to stay clear of.

I serve walk in patients in a clinic with several doctors who have full time practices.
I see their over flow of patients in a timely manner and my EMR encounter records are readily available for the patients family physician, to provide suvsequent,follow up care if needed

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.